Healthcare Provider Details

I. General information

NPI: 1245566934
Provider Name (Legal Business Name): MARY MAY GILLETTE L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 S GLENORA RD
DUNDEE NY
14837-8842
US

IV. Provider business mailing address

81 S GLENORA RD
DUNDEE NY
14837-8842
US

V. Phone/Fax

Practice location:
  • Phone: 607-243-8714
  • Fax:
Mailing address:
  • Phone: 607-243-8714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2568451
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: